Independent Medical Opinion (IMO) / Nexus Letter
This hot little ticket is the key to turning your Claim or Appeal from a dud to a stud. It provides your claim with one of the key elements that all claims need to be successful. Which is a medical opinion that your disability is a result of your military service or an already service-connected disability.
NOTE:
An IMO is NOT a DBQ and a DBQ is NOT an IMO! For more information about DBQs click HERE.
IMPORTANT NOTES:
An IMO is NOT required to be submitted by you for your claim or appeal to be successful, so please do NOT feel obligated to include one! This is more for Veterans who's claims may be more complex, be it due to time since separation, controversy, confounding factors, etc.
As an IMO is primarily a records review and the application of medical knowledge/expertise, it is NOT necessary for the Veteran to meet face to face with the doctor who prepares the IMO.
Who Should Write an IMO
For an IMO to have any weight it should be completed by a medical expert. The more experienced and specialized the expert, the better.
This medical expert should be:
Currently Board Certified in their field of study and their expertise should be relevant to the Veteran's focus. For example:
Audiologist - Hearing loss or Tinnitus.
Cancers - an oncologist.
Disabilities relating to old bone injuries - an orthopedic surgeon.
Psychiatrists;
Physiatrists;
Neurologists; or
Neurosurgeons.
Board-certified or board-eligible psychiatrists;
Licensed doctorate-level psychologists; OR
One of the following other mental health professionals, under the CLOSE supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist:
Doctorate-level mental health providers
Psychiatry residents; and
Clinical/Counseling psychologists completing a one-year internship or residency.
NOTE:
“Close supervision” means that the supervising psychiatrist or psychologist met with the Veteran and conferred with the examining mental health professional in providing the diagnosis and the final assessment. The supervising psychiatrist or psychologist must co-sign the examination report.
SPECIAL NOTE:
For PTSD, the examining psychiatrist or psychologist should comment on whether the Veteran has experienced other traumatic events and, if so, indicate the relevance of these events to the current symptoms.
Where to get an IMO
Ideally, you should get your treating physician to prepare it for you.
Unfortunately, if your treating physician is from the VA, you are kinda out of luck. The Veteran Health Administration (VHA) is primary concerned with treating Veterans. And as such, helping Veterans with their claims is generally outside of the scope of their job.
Your VA Physician is permitted but not required to assist you with an IMO, and many would rather focus their efforts on treatment.
So you may have to search out a private physician.
IMPORTANT NOTE:
PLEASE DO NOT GO ONLINE AND USE SOME SITE THAT PEDDLES IMOs and DBQS! You'd be best served going through your own treating physician or someone else who is local.
Important Things an IMO Should Include
Here are a few things that your physician should be sure to include in their IMO:
Letter should only be the length needed. It should be direct and stick to the facts.
Statement that the physician has reviewed all of the Veteran's relevant/available pre/post medical records as well as of course the Veteran's military medical records.
If there are things in your records which detract from a favorable opinion (other things could also cause your condition), these things SHOULD be discussed! Why? Because it shows consideration was given to the entirety of the record. To not show consideration shows a lack of attention to detail - which a rater CAN use to assign their opinion lower weight!
A rationale which explains why the condition is related to the Veteran’s service/service-connected disability.
This rationale MUST be supported by the evidence of record and have appropriate supporting medical proofs/studies.
The rationale should be in reference to a specific diagnosis. Giving an vague opinion on a non-specific condition is a GREAT way to get a rater to assign the opinion little to no weight! As failure to provide a diagnosis indicates your medical evidence has not been reviewed or that you have not been properly examined by them.
This rationale should also be specific and avoid the use of wide-sweeping generalizations without reference to specific events or duties.
Vague statements of “duties” or “hardships” should be avoided; instead expressly state what those duties and hardships were. And then explain how they caused X condition.
Statement regarding their opinion* as to if the Veteran's current disability is service-connected/or related to a Veteran's service-connected disability.
*This statement does NOT need to be absolute, as it can be really hard to be absolute with the origin of things.
The language the VA uses and understands regarding statements of service-connection are as follows:
Is not related: 0% chance disability is service-connected.
Less likely than not: Less than 50% chance disability is service-connected.
As likely as not: 50% chance disability is service-connected.
More likely than not: More than a 50% chance disability is service-connected.
Is related: 100% chance disability is service-connected.
IMPORTANT NOTES:
If your IMO is countering a prior negative opinion, the IMO should also address why the VA examiner is wrong or why your argument is stronger. This will add more weight to the IMO - as it shows a deeper consideration of the medical evidence.
For VA purposes, if the likelihood is at least 50% then the VA considers it a POSITIVE opinion for the purposes of establishing service-connection!
Statements like “may have”, “possibly caused”, or “could have” do not fit into the above framework and are NOT considered favorable!
Nexus Letter Example
Here is an example that you can show your doctor to give them more of an idea of what you are looking for:
Date _________________
Reference: _________ (Veteran's name)
To Whom It May Concern,
I am Dr. _________, I am medically licensed and board certified in my specialty of __________ in the state of ________. My credentials are included below. I have been asked to write a statement in support of the aforementioned Veteran's disability claim.
MS/MR/MRS. ________ is a patient under my care since (Date).
I am familiar with their medical history and have personally examined MS/MR/MRS _________. Their diagnosis is ___________ (Name the condition and specify lab work, X-rays, etc. used to make this diagnosis determination)
I have personally reviewed their medical history (Service Treatment Records, VA Medical Records, Private Medical Records From X, Y, etc). I have also reviewed and have noted the circumstances and events of their military service in the years ____________ (Event or Events stated as the cause of the condition) while they served during their military service in the ________ (Branch and dates of service).
MS/MR/MRS. ________ has no other known risk factors that may have precipitated their current condition. [IF Veteran has risk factors state them and explain why you find they are less likely the cause of the diagnosed condition]
After a review of the pertinent records it is in my professional opinion that it is at least as likely as not that MS/MR/MRS. ________'s ______ (Condition) is a direct result of their _______ (Event) as due to their military service. OR secondary to their service-connected ______ (Condition(s)).
In my personal experience and in the medical literature it is known ______ (Provide a rationale AND references to medical literature).
Signed,
Dr. ______
(List credentials and contact information)
Final Words
Let there be no confusion here. Please do NOT go IMO shopping!
If the physician determines that your disability is less likely than not due to your military service/service-connected disability then you should generally accept this. If you do disagree with them you are of course free to get a second opinion - just don't keep trying to find the one doc that will go along with you.
Frequently Asked Questions
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The tie principle is NOT applicable here. Because the two are not equal. If for instance the C&P examiner was more experienced, specialized, etc. Their opinion may have carried more weight than your IMO. However, you should have your claim reviewed by a VSO. So they may help guide your through the Appeals process. Since the VA may not have properly considered your IMO.
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It is kind of a misnomer. It is independent with respect to the VBA. IE it is an opinion from someone not affiliated with the VBA.
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While it may be a matter of personal/professional policy for them, it may also be that want to be properly compensated for their work and time. As such, you should make it clear that you will compensate them appropriately. It will take them time to go through your records, do any relevant research, type up the opinion, etc. and physician time isn't cheap - this will cost you at least a thousand dollars, possibly quite a bit more.
If they are still unwilling, you will then have to seek out another physician.
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It is a dice roll. If the VA finds issue with your evidence they can assign it low/no evidentiary value. But… if you think your paperwork is in order you can cancel the exam, just be aware it may not pan out in your favor.
If you are denied for not attending the exam you may find filing a Higher Level Review appropriate.
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Sure thing! Just be sure they provide evidence of their licensing/credentials.
The IMO also does NOT have to be translated to English, but it would speed things up if it was.
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No, but it is generally a good idea as it would have their practice’s information and give it an increased air of authority and authenticity.